Children living with HIV should be followed up closely in the health-care system and should be screened for TB at every routine contact with an HIV care provider, at a health facility or in the community. Given the high risk of progression to TB disease and the high mortality rate, combined symptom screening should also be done at every contact with the health-care system, including events such as vaccination days, maternal health appointments, at nutritional screening and at food support programmes. The combined symptom screen has low specificity, which may lead to a large number of false-positive screens and unnecessary diagnostic tests or treatment for TB. Nevertheless, given the high mortality due to untreated TB among children living with HIV, the risk of overtreatment is often outweighed by the benefit of TB treatment. Health-care workers should closely monitor therapy and remain vigilant to the possibility of a false-positive TB diagnosis when the symptoms are due to another disease, such as pneumonia.
It may be difficult to determine whether a child has close contact with a person with TB, and it is important to take a careful history of the known exposures of the caretaker and the child. Household contacts are often considered, but, particularly in areas with a high TB prevalence, close contact can occur in a variety of community settings, including school, day care and religious gatherings. A study in South Africa indicated that only half of children with TB had a known household contact with TB (44), and even young children had a high risk of being infected in the community, not just from household members with TB. Therefore, a high index of suspicion of TB in young children should be maintained, especially for children with HIV or of unknown HIV status in settings with a high TB prevalence.
Children living with HIV who are found not to have TB disease should receive TPT as per WHO guidelines (4, 5).